PROMIS Item Bank v. 1.0 – Physical Function – Short Form 20a
Physical Function – Short Form 20a
Please respond to each item by marking one box per row.
PFA11
PFA12
PFA16
PFA34
PFA38
PFA51
PFA55
PFA56
PFB19
PFB22
PFB24
Without
any
difficulty
With a
little
difficulty
With
some
difficulty
With
much
difficulty
Unable
to do
Are you able to do chores such as vacuuming or
yard work? ................................................................





5
4
3
2
1
Are you able to push open a heavy door? ..........





5
4
3
2
1
Are you able to dress yourself, including tying
shoelaces and doing buttons? ...............................





5
4
3
2
1
Are you able to wash your back? .........................





5
4
3
2
1
Are you able to dry your back with a towel? ........





5
4
3
2
1
Are you able to sit on the edge of a bed? .............





5
4
3
2
1
Are you able to wash and dry your body? ............





5
4
3
2
1
Are you able to get in and out of a car? .............





5
4
3
2
1
Are you able to squeeze a new tube of
toothpaste? ............................................................





5
4
3
2
1
Are you able to hold a plate full of food?.............





5
4
3
2
1
Are you able to run a short distance, such as to
catch a bus? ……………………………………...





5
4
3
2
1
© 2008-2012 PROMIS Health Organization and PROMIS Cooperative Group
Page 1 of 2
PROMIS Item Bank v. 1.0 – Physical Function – Short Form 20a
PFB26
PFC45
PFC46
PFA1
PFA3
PFA5
PFC12
PFC36
PFC37
Are you able to shampoo your hair?......................
Are you able to get on and off the toilet? ...........
Are you able to transfer from a bed to a chair and
back? .....................................................................
Without
any
difficulty
With a
little
difficulty
With
some
difficulty
With
much
difficulty
Unable
to do





5
4
3
2
1





5
4
3
2
1





5
4
3
2
1
Not at all
Very little
Somewhat
Quite a lot
Cannot do
Does your health now limit you in doing
vigorous activities, such as running, lifting
heavy objects, participating in strenuous sports?





5
4
3
2
1
Does your health now limit you in bending,
kneeling, or stooping? .........................................





5
4
3
2
1
Does your health now limit you in lifting or
carrying groceries? ..............................................





5
4
3
2
1
Does your health now limit you in doing two
hours of physical labor?....................................





5
4
3
2
1
Does your health now limit you in walking more
than a mile? .........................................................





5
4
3
2
1
Does your health now limit you in climbing one
flight of stairs? ......................................................





5
4
3
2
1
© 2008-2012 PROMIS Health Organization and PROMIS Cooperative Group
Page 2 of 2